A Report on the Future of Farming and Food
Edited by Tim Lang and Geof Rayner

With contributions from:

• Prof Annie Anderson, Department of Medicine, University of Dundee
• Angela Blair, Health Promotion Department, Sandwell Health Authority
• Dr Eric Brunner, Department of Epidemiology and Public Health, University College London
• Dr Martin Caraher, Centre for Food Policy, Thames Valley University
• Dr Elizabeth Dowler, School of Health & Social Studies, University of Warwick
• Prof Ken Fox, Dept Nutrition and Exercise, Bristol University
• Prof Sian Griffiths, President, Faculty of Public Health Medicine
• Dr Andy Jones, Research Officer, Sustain
• Prof Tim Lang, Centre for Food Policy, Thames Valley University
• Paul Lincoln, Director, National Heart Forum
• Dr Erik Millstone, Science Policy Research Unit, University of Sussex
• Prof Jules Pretty, Centre for Environment and Society, University of Essex
• Dr Mike Rayner, BHF Health Promotion Research Group, Oxford University
• Dr Geof Rayner, Chair, UK Public Health Association
• David Rex, Health Promotion Department, Sandwell Health Authority

Endorsed by the following organisations:

Chartered Institute of Environmental Health
Faculty of Public Health Medicine of the Royal Colleges of Physicians
National Heart Forum
UK Public Health Association

Supported by the Health Development Agency

In 2001, the re-elected Labour Government set up a Policy Commission on the Future of Farming and Food charged to report by the end of the year (although subsequently given an extra month).¹ The Commission had the following formal terms of reference:

"To advise the Government on how we can create a sustainable, competitive and diverse farming and food sector which contributes to a thriving and sustainable rural economy, advances environmental, economic, health and animal welfare goals, and is consistent with the Government's aims for CAP reform, enlargement of the EU and increased trade liberalisation." (Our emphasis).

The scope of the Policy Commission was restricted to England although its deliberations are being noted in other parts of the United Kingdom. Our Report accordingly focuses on England but provides some UK data where none other is available.

This present Report was produced by a group of academics and specialists concerned to ensure that public health and environmental arguments are heard in the national debate. The Report is endorsed by a number of major public and environmental health bodies.

This Report says that health is the central consideration of the nation's farming and food system. It examines the health and health inequality impact of current farming and food policy and the externalised costs of current policies and proposes a fresh direction for change. It argues that England needs a modern, reformed Farming and Food Policy which takes full account of the health of the population and the Government's support for tackling health inequalities and the principles of sustainable development. Health, therefore, is the key to the future of farming and food in England.

Health is something that is often assumed within food and farming policy, frequently misunderstood and too often considered only as an afterthought. This Report can do no more than outline what is a complex story to tell. It suggests some key parameters that could and ought to change. It offers policy recommendations.

This Report argues that:

• Health has to be central to any vision and practice for the future of food and farming;
• A poor and costly record on health is part of what has brought the crisis in British food and farming to a head;
• The key purpose of food and farming is - or should be - to advance the health and well-being of the population;
• Other considerations such as the economy, trade liberalisation, CAP reform, etc., should all meet this goal of improved public health; if they do not, they should be rejected;
• A new integrated approach to health -- linking nutrition, food safety and sustainable food supply, an approach here called ecological public health -- would provide the food and farming industries with a new framework that they desperately need;
• Farming practices which sustain environmental improvement -- namely to reduce energy use, to increase variety and biodiversity and to conserve amenity for the public -- are congruent with one at the same time those which are most effective in promoting public health;
• There should be a population approach to farming and food policy on top of the current market and individual focus;
• The food supply change needs to deliver affordable, health-enhancing and accessible diets for all, not just for those who can afford it.

After half a century of production-driven farming and food policy, the old model has outlived its usefulness. There should be a new set of national principles and strategies for farming and food policy:

• Farming and food strategy should put health for all as a central tenet.
• Farming and food should give equal weight to both human and environmental health.
• Policy and practice should encourage diversity of foods and biodiversity in fields.
• The food supply chain should decrease its reliance on non-renewable energy over and above global, European and UK commitments.
• Food costs should more fully reflect their real costs of production, distribution and mal-consumption.
• Geo-spatial planning -- particularly for retailing and transport -- should facilitate physical activity in line with national health strategies and to reduce social exclusion.
• Food supply chains should be as local and as short as possible.
• The revitalisation of food culture in England should be supported in schools, local partnerships and provision.
• Encouragement should be given to local food providers and suppliers to rebuild local economies.
• A reduction of diet-related inequalities to tackle social exclusion and poor access should be at the heart of farming and food systems.

The entire food supply chain needs to know and share an overall policy framework. This should outline a clear and coherent vision and set medium and long-term goals. To that end:

• A national food and farming policy should be published with clear objectives, setting out principles, objectives and aspirations for each sector of the food supply chain.
• An annual report on Farming and Food Policy should be published jointly by DH, DEFRA and the FSA, to fill the policy monitoring role left void by the demise of the old Annual Review of Agriculture; this should be subject to scrutiny by the parliamentary Select Committee on Environment, Food and Rural Affairs.
• Farming and Food Policy should be based on the WHO European 'Three Pillars' model, which gives equal weight to food safety, nutrition and the promotion of a sustainable food supply.

Government has to take a lead in setting the new health oriented farming and food policy. It should now set out new measures and create new institutions to carry forward the task of modernisation. These include:

• New approaches to policy-formulation. To conduct health audits after policies have been framed is not sufficient. What is needed is a commitment to integrate policy threads from the start rather than trying to 'filter' them via audits for health, inequalities or environmental at a later stage. Such considerations need to be built in from the outset.
• A new national Food Policy Council should be set up to advise on an overall view of farming and food policy. This is needed not to duplicate the functions of existing bodies (FSA - safety; DEFRA - production, DH - human health etc) but to ensure that there is an overview that links the entire supply chain into a coherent framework. It should also provide expert advice. Improved co-ordination is needed between DEFRA, DH and the FSA.
• Defining core goals for the next 30-50 years, to include, for example, the encouragement of local food suppliers, providers and retailers to reduce 'food miles', ensuring that all citizens are within walking or bicycling distance of food shops

Financial measures current encourage policy confusion: conventional 'efficiency' in some areas (e.g. processing) and ecological efficiency in other areas (e.g. waste reduction). The Treasury should review how fiscal measures can help deliver a more rounded ecological model of health, thus helping the government to achieve its targets in health and sustainability. Reduction of crisis payments as for BSE or Foot and Mouth Disease are likely to continue unless fiscal measures incorporate the full range of health thinking. Priority therefore be placed on:

• Re-directing Common Agricultural Policy subsidies to promote greater diversity and sustainability;
• Eliminate subsidies to anti-health crops like tobacco;
• Long-term studies of how fiscal measures can affect health behaviour; this to review politically 'dangerous' measures such as VAT as well as 'win win' positive measures such as how to encourage greater production and consumption of UK-grown health-enhancing foods.

Policy cannot be made at the national level alone. England, is part of the UK, which is part of the EU, which is also set within other global commitments such as the General Agreement on Tariffs and Trade, health and environmental treaties, etc. England and the UK also have to address the local dimension of multi-level governance. Policy co-ordination is required across these multiple levels of food governance to give greater emphasis to the promotion of a vibrant food economy whether at local, national, regional and global levels.

In particular, lower tier policy development should:

• Invigorate action at local and Regional Development Agency levels;
• Promote local food partnerships (local strategic partnerships), comprised of local authorities, health authorities, NGOs and citizen groups to audit their local food provision and to work with local suppliers to improve it in line with meeting health and environmental goals;
• Local authorities and the new Primary Care Trusts should institute a food dimension within their health improvement and community plans to monitor food access and food inequalities within their localities (along with other actions on physical activity, sustainability, etc, as profiled in this Report). Annual reports should be made public and should inform revisions of local strategic plans.

The farming sector sits at the centre of a complex, capital intensive supply chain. It has done what it was asked to by the 1947 Agriculture Act: increase production and make Britain less reliant on the vagaries of trade and insecurity of war. Entry to the Common Market, now European Union, changed the mechanisms and context but little of the goals. The challenge for the 21^st century is now to go beyond mere quantity goals. The emphasis has to be on quality and on giving priority to certain sorts of foods -- to delivering a balanced diet in a sustainable way. From this ecological and human health perspective, the priorities are to:

• Increase domestic production of fruit and vegetables by providing a combination of better financial incentives, skills support and marketing advice;
• Use the production, distribution and consumption of fruit and vegetables as a key indicator of 'joined up' food and farming policy across government;
• Initiate a 20 year plan to reduce dairy and animal fat production to provide a diet which meets the WHO and the EU's Eurodiet population goal to have a maximum of 30% of energy derived from fats;
• Set a goal to judge farming by its biodiversity of production and methods; this should encourage biodiversity in fields and not just in 'wildlife' zones or at the edge of fields.

The structure of the current food supply chain needs to reflect the needs of everyone, not simply the financially better off or the most mobile. To achieve this requires co-ordination between the Department of Trade and Industry, the Department for the Environment, Food and Rural Affairs and the Department of Local Government, Transport and the Regions, with the Department of Health and the Food Standards Agency. These government organisations, in alliance with local agencies of government, should:

• Encourage local food suppliers, providers and retailers to reduce in 'food miles', ensuring that all citizens are within walking or bicycling distance of food shops;
• Inject an ecological health and population approach into business strategy which currently too often sees health as a matter of individual choice;
• Include a Health Inequalities and Environmental impact analysis and goals into the retail planning process;
• Implement recommendations made in the Social Exclusion Unit's Policy Action Team 13 report and that the Urban Task Force chaired by Lord Rogers of Riverside to make food shops more local, in particular by the introduction of a 20 year commitment to rebuild local food shopping;
• Disseminate and refine social mapping techniques, such as that used in the Sandwell study, and encourage their use by local, regional and national bodies in order to help consortia of local health bodies and the food sector to achieve health inequality targets and to improve access to shops.

English food culture has exhibited divergent trends over recent decades. There is more diversity for some and greater public interest, alongside evidence of food worries and lack of skills and inequalities for others. A medium-term strategy is needed with the Department for Education and Skills and DEFRA as its central drivers. They should:

• Introduce a new practical food skills element into schools education;
• Restrict food advertising targeted at young people, either by toughening up the Code of Advertising Standards or by statutory means;
• Promote ethical guidance in schools regarding the promotion of food and drink;
• Set and monitor tougher standards for all school food provision, including school meals.

The food sector and the public at large both require a new Research and Development agenda. Previous attempts to think about the role of R&D have been industry and competitiveness-led. The health dimension has therefore tended be viewed as a technical problem. Health, it is falsely assumed, can be 'fixed' by magic health 'bullets' and the search is on for products not a diet as a whole. This needs to change. DEFRA and the FSA should:

• Introduce a new R&D agenda that develops incentives for healthier diets;
• Invest in research to reduce scientific uncertainties which cloud advisory committees work assessing risks and advising policy-makers;
• Support more environmentally-sustainable ways of producing, processing and distributing food;
• Take as a priority the need to cut greenhouse gas emissions from the lengthening food supply chain; this could emulate the Swedish commitment to reduce energy use across the supply chain by a factor of four by 2020.

Good health is the top of most people's concerns. When asked to judge which of several factors among a list of ten or so things that are 'most important for you personally in determining how happy or unhappy you are in general these days', most people in a recent British survey said 'health' (59%), followed by 'family life' (41%) and then 'marriage/partner' (35%) and then 'job/employment of you/your family' (31%). These factors stood well above education received (7%), housing conditions (9%) or even financial condition/money (25%).² The achievement of good health has, historically, not been determined by medicine alone but by a large range of determinants, including, centrally, the availability of wholesome, healthy and affordable food.

For industrially advanced societies like England, which pioneered the revolution in farming methods, consumers have experienced a remarkable change in what they eat and how it gets to them. In fact, the relationship between food and health is not only recent but the story of evolution itself. Over millennia, human physiology developed an astonishingly sophisticated combination of ways for turning nutrients into bodily outputs -- movement, thought, dexterity -- that underpin our daily lives. The human capacity to store fat, for instance, possesses an evolutionary value that in the era of full supermarket shelves is hardly a necessity. As we show later, a key problem is over-consumption, as well as the continuation of pockets of under consumption (which are exacerbated by issues such as the siting of food retail stores, and advertising). The food revolution of the last century (particularly the last half) means that we now eat many new foods, a diet that is processed in new ways, delivered and cooked through new techniques. This diet enters bodies whose pathways and mechanisms were not necessarily designed for them in the combinations and form we can consume them in. We are thus constrained by our genetic past while experiencing our consuming present.

Seen through the prism of centuries, there have been vast improvements in the British diet -- notably increased quantity and variation, reduction of contamination and gross adulteration -- which have been key factors in increasing life expectancy of rich countries such as our own. But there have also been new sources of under-, over- and mal-nutrition, contamination and adulteration.

Food is a key indicator for global health divisions (see Table 1). The UK may firmly sit among the ranks of the favoured yet it is among the worst affected by diet-related ill-health. In other words, there is a paradox; the picture is partly rosy and partly exhibiting extremely worrying trends. While under-nutrition in the UK is extremely rare, diet and over-consumption is a key factor in the main causes of premature death. This has been long recognised.³ Diet-related ill-health and early death are linked to cardiovascular disease, some cancers (e.g. breast, colon),⁴ strokes, diabetes ⁵ and hypertension.⁶ The list of diseases with a dietary link is long.

Source: first 3 columns adapted from Gardner & Halweil 2000,¹⁰ based on WHO, IFPRI, ACC/SCN data; 4^th column present authors' own based on data from this Report

One aim of the Policy Commission on the Future of Farming and Food was to advise the Government on how a 'sustainable, competitive and diverse farming and food sector' 'which contributes to ... health goals' could be created. The present Report suggests:

• A way of determining what those health goals should be, through an assessment of the burden of food-related ill-health. Such an assessment indicates that the primary health goals should be to reduce diet-related cardiovascular disease (CVD) and cancer. Secondary goals -- as important in relation to public health -- should be to reduce ill-health due to the microbiological and chemical contamination of food.
• That health goals relate to economic goals in that reducing the burden of ill-health would have economic benefits. Reducing diet-related CVD and cancer rates could have greater economic benefits than reducing ill-health de to microbiological and chemical contamination of food.
• That health goals need not conflict with other goals for a sustainable, competitive and diverse farming and food sector: in particular that environmental goals and health goals are entirely congruent and complementary. In order to advance both environmental and health goals there needs to be a switch from the production of animal-based foods to plant-based foods -- particularly vegetables and fruit. There also needs to be an emphasis on increasing bio-diversity in the agriculture system both to protect ecosystems and to ensure a varied diet.

The terms of reference for the Policy Commission accept that the farming and food sector should contribute towards health goals. But which health goals should the farming and food sector contribute towards? This Report suggests a way of determining what those goals should be. It is proposed that the goals should relate to:

• the most important and persistent public health problems; and
• public health problems which the farming and food sector in particular could contribute towards alleviating.

The Government's NHS Plan sets out the importance of nutrition and action to improve it to reduce health inequalities.¹¹ Its earlier White Paper: 'Our Healthier Nation' sets out its health goals.¹² These are, in summary, to reduce rates of:

• cardiovascular disease (CVD);
• cancer;
• mental ill health;
• accidents.

The food and farming sector could potentially contribute to all four but can contribute more to some than to others. CVD and cancer are the most prominent targets because they deal with the whole of society and the links to diet are now well understood. While the mental health of agriculture workers is probably deteriorating, in large part associated with the declining economic health of the industry, the numbers are comparatively small. There is evidence that diet is factor in some mental ill-health conditions. The proportion of children exhibiting psychological symptoms of Attention Deficit Hyperactive Disorder, for example, is anywhere between 5% and 50%. It has been estimated that for a significant minority of children in many industrialised countries, dietary change might improve the mental health and education prospects for up to 10% of children.¹³ Accidents (e.g. on farms, in premises involved in the processing of food, etc) need to be reduced.

The main purpose of the farming and food sector is to produce food and the food it currently produces -- while clearly having some positive health benefits -- also causes significant health problems in relation to CVD and cancer. The high rates of CVD and cancer in England are partly a consequence of the diet being too high in fat, particularly saturated fat, and salt and too low in dietary fibre, complex carbohydrates and certain vitamins and minerals. The science demonstrating the causal relationship between poor diets and CVD, cancer, etc., has been extensively documented elsewhere. The Eurodiet project of the European Commission has now set new health goals for diet.¹⁴ These are summarised in Table 2. This table was the culmination of advice and a process involving 200 scientists in the European Union. It set desirable population goals for physical activity, body mass index (a measure of body weight in relation to size), and intake of fats, carbohydrates, fruit and vegetables, folate, sodium (salt) and iodine. It also made recommendations about breast-feeding.

The UK Population, as whole, is currently consuming a diet that far in excess of these health targets. According to National Food Survey 1999 data, 38% of energy is currently derived from total fats, when the target is for it to be less than 30%.

Approximately 14% of energy is currently derived from saturated fats, when the target is less than 10%.¹⁵

Source: Eurodiet 2000 ¹⁶

Even in relation to CVD and cancer the farming and food sector is only part contributor towards the attainment of goals. CVD and cancer are caused, not only by poor diets, but also by smoking, physical inactivity, hereditary factors, etc. The farming and food sector can also contribute to other health goals - particularly those relating to microbiological and chemical contamination of food (food safety), but it is proposed that the farming and food sector could make a larger contribution to public health as whole though contributing to goals for CVD and cancer rates than though contributing to an improvement in food safety. The reasons for this are set out in the next section.

Farmers and the food industry have been encouraged to increase supply since the 1947 Agriculture Act. From a situation where large amounts of fat were imported in the form of both dairy and vegetable fats (e.g. for margarines), the UK now produces huge amounts, in dairy, meat and vegetable forms.

There is evidence that CVD and cancer are partly, even largely, a consequence of the English diet -- a problem shared with the rest of the UK -- being too high in fat, particularly saturated fat, and salt and too low in dietary fibre, complex carbohydrates and certain vitamins, minerals and 'essential' fatty acids. An awareness of this has led to many expert committees setting population-based nutrient goals (for a recent summary, see Eurodiet).¹⁷ When specialist teams set dietary guidelines to tackle specific diseases like CVD, cancer and indeed other diet-related health problems such as diabetes, the nutrient goals turn out to be almost the same. In other words, while confusion about diet is rampant there is scientific consistency about what a desirable diet should entail. These recommendations ought to set a broad production framework for agriculture and industry.

It should be noted that levels of overweight and obesity are increasing rapidly -- a topic which appears throughout this Report -- and that this is contributing to the high levels of CVD (particularly through their effects on Type 2 diabetes, a major cause of death and disability in its own right, but also a significant cause of CVD) and cancer. Overweight and obesity are caused partly by high fat and low complex carbohydrate levels but also by low levels of physical activity. The evidence suggests that children, even in pre-school years, are gaining weight and that the proportion with weight problems are growing rapidly. Of course, the reasons for the decline in physical activity are complex, but at least part of the explanation is changes in culture, including food culture, in particular the use of private transport for shopping or transportation of children to school. Access to the countryside is also of consideration here.

Focusing solely on the food component of these problems, nutrient goals can be achieved in different ways in different populations. For example increasing complex carbohydrates can be achieved by eating more potatoes, pasta or rice. But in general the attainment of nutrient goals for fat, saturated fat, dietary fibre, complex carbohydrate and many vitamins and minerals would require a reduction in consumption of meat and dairy produce and an increase in consumption of plant- based foods -- particularly vegetables and fruit. (Incidentally this would also result in a reduction in health problems associated with microbiological contamination of food since micro-biological contamination of plant-based foods is comparatively rare).¹⁸

The attainment of nutrient goals would also be easier to accomplish if diets were more varied, particularly in plant-based foods but also, for non-vegetarians, in the types of animal products. This is where the exciting connections between what the English population (and other UK national groupings) require for nutritional grounds and the demands for a more sustainable food supply -- landscape and ecology -- coincide.

Promoting a diverse diet, rich in vegetables and fruit, are the human consumption counterparts to the promotion of biodiversity in the fields.

This section argues that the current food policy and structure of food and farming is not achieving what it could or should:

• People are suffering avoidable morbidity or dying prematurely from diet-related illnesses, with indications that some trends, such as obesity, are set to become far worse;
• The UK has an unnecessarily high level of health inequalities, with diet playing a major role;
• There are emergent risks to human health due to food production methods;
• Social and cultural forces are encouraged which work against, rather than for, public and environmental health;
• The economic costs associated with the above are externalised. They are born by the State, consumers and through environmental degradation;
• EU and Common Agricultural Policy drivers have marginalised health;
• UK and EU farmers operate in a setting of perverse incentives, thereby producing foods which ignore population health considerations;
• The food system is excessively reliant on non-renewable fuels which underpin the undesirable growth of food miles.

There are two main types of health problem in relation to food consumption:

• problems due to micro-biological and chemical contaminants in food i.e. food-borne diseases; and
• problems due to the composition of the diet, i.e., diet related diseases.

Food born diseases -- prominent examples being campylobacter, salmonella, variant Creuzfeldt-Jakob Disease (vCJD), ill-health due to pesticide residues in foods, etc. -- have been the subject of recent food scandals with huge economic costs and some -- but in fact relatively small -- costs in terms of public health.¹⁹ These are summarised later.

In contrast, annual toll associated with diet-related disease is far larger. This category includes CVD, cancer, diabetes, dental caries, osteoporosis, vitamin, anaemia due to iron deficiency, etc.

Calculating the burden of ill-health due to food-born diseases and poor diet in England and similar developed countries is becoming increasingly sophisticated. The World Health Organisation (WHO) is currently carrying out such a study, the results of which should be available in the summer of 2002. In the meantime we can draw some relatively clear conclusions.

Table 3 shows the level of DALYs -- disability adjusted life years -- lost from the major causes of ill-health in England. The DALY is a measure of the burden of disease in terms of both mortality and morbidity and are a supplement to death rates and other older indicators of disease. The number of DALYs lost is the sum of years of life lost in early death with years of life lost in disability.

Source: Murray CJL, Lopez AD (1996) The Global Burden of Diseases. Geneva: World Health Organisation

Table 3 indicates that diet-related diseases (i.e. CVD, cancer, diabetes and nutritional deficiencies) in developed economies are responsible for about 35% of DALYs lost, but that diarrhoeal diseases (salmonella, campylobacter, etc) are responsible for only 0.2% of DALYs lost. To put it more bluntly, food safety may scandalise the country and attract political attention, but it is the routine premature death by degenerative disease that extracts the greater ill-health toll.

It is variously estimated that about one third of the DALYs lost due to CVD and cancer are because of poor diets. Because CVD and cancer are two of the three major causes of DALYS lost (the other being mental health problems) then we can say that about 10% of all DALYs lost are due to poor diets, i.e., about 50 times the numbers of DALYs lost due to ill-health resulting from microbiological or chemical contamination of food.

Table 4 shows the results of two studies which also conclude that a similar proportion of DALYS lost in developed economies are attributable to poor diets. Table 4 also shows that both studies conclude that about 10 % of DALYS lost are due to poor diets. Note that 10% is about the proportion of DALYs lost due to smoking.

Britain has a poor record among affluent countries for diet-related deaths. Table 5 gives data on deaths from CHD, comparing Britain's to other countries' records over the last three decades. Britain has the worst record for women and is second worst for men.

Sources: National Institute of Public Health, Stockholm (1997) ^20,21

* latest statistics for 1994

Tables 3-5 suggest that the most important health targets for the farming and food sector should be those which to contribute to the reduction of CVD and diet-related cancer. A reduction in CVD and cancer could be achieved through changes in the food and nutrient composition of the diet leading to a huge improvement in public health overall. There is considerable resistance from within the food industry to such suggestions. Arguments rehearsed include the view that consumer choice is paramount; that to set health targets smacks of the 'nanny state'; or that consumers are resistant. Such arguments are addressed later.

The evidence shows that degenerative diseases are overwhelmingly diet-related. However, this fact should not be taken to imply that we would support any weakening of health goals being set for food-born diseases (or indeed diet-related diseases other than CVD or cancer); the case made is that the reduction in CVD and cancer has to assume far greater prominence on the farming and food policy agenda.

While the evidence suggests that degenerative disease ought to be the main priority in health, we do not mean to imply that food safety is unimportant. Food safety has in fact dominated public debate and governmental response for over a decade. The incidence of food poisoning is still unacceptable (see Figure 1) and, although reported incidents have levelled off, key indices such as E Coli 0157 (which killed people in the 1997 Wishaw outbreak) are worrying (see Figure 2)

The Food Standards Agency (which spends 12% of its budget on food-borne illness) is committed to reduce food-borne illness by 20% by 2006.²² The FSA estimates that food-borne illness currently costs the economy £350 million a year, while other estimates have suggested the true cost may be as much as £1 billion per year.²³ Another study found that the care costs to the NHS for 100,000 people treated for food poisoning in 1991-94 was £83 million.²⁴ In the USA costs per person are higher, mainly due to litigation.

The Pesticides Residues Committee (formerly the Working Party on Pesticide Residues) finds occasional batches of food products which exceed the Acute Reference Dose.²⁶ Over recent decades residues have consistently been found by government research but rarely at serious levels providing evidence of direct and lasting harm to health. Nonetheless, a symbol of the persistent niggles about pesticide residues was the situation in 1995 when the Working Party on Pesticide Residues found excessive residues in carrots, following which the Chief Medical Officer issued advice in 1997 to peel carrots. This advice is still routinely given but the Food Standards Agency thinks that peeling is not necessary and there is currently some negotiation between the FSA and the PRC about whether the CMO's advice to peel carrots is still needed. Whether this is so or not is almost beside the point. The fact that so-called Good Agricultural Practice allowed application of pesticides to carrots in such quantities that consumer safety was even slightly in doubt suggests that agricultural production was coming before consumer safety. The Co-operative Group and Marks & Spencer are banning particular pesticides in their supply chain despite it having official government approval.^27,28 Such companies are, in effect, voluntarily applying the precautionary principle while such actions should be spread throughout the sector as a matter of course.

What is needed is a pesticide reduction policy, not just for consumer safety but also to protect farmers and farm workers from harmful exposure. This new policy should go beyond the current pesticide minimisation policy which de facto permits pesticide use. While this policy does acknowledge some health concerns, it still lacks strategic perspective on reduction in their use. By implication, safer alternatives to pesticides should be a research priority in the new farming policy. It must be acknowledged that this is an issue which does not affect the UK alone.

The latest published government figures on poverty in the UK show that there were 4.5 million children living in poverty in the UK in 1998/9 (35 % of the population), this contrasts with 1.4 million or 10% in 1979.²⁹ The definition of poverty used is households whose income is 50% of average after housing costs have been deducted. This increase is in contrast to most industrialised countries where child poverty has remained static or fallen in the past twenty years.³⁰

In recent years, the evidence of the health divide within Britain's population has become unassailable, as was shown by the Independent Inquiry into Inequalities in Health (Acheson Report).³¹ The general lines of the Report were accepted by the government and action to combat health inequalities now assumes a central place among policy making. The Acheson Report showed that the reasons explaining health inequalities are complex but essentially that there is a high degree of income inequality, huge variation of life opportunities, education, housing and employment. Diet plays a significant role in the resulting health inequalities.

In recent years, although overall incidence of CHD has dropped (see Table 3), the gap between rich and poor Britons has widened (Figure 3). Many of the reasons are directly related to food; many are directly related to the circumstances surrounding the acquisition of food. There is considerable evidence that a sizeable proportion of the UK population suffers from inadequacy of diet due to low income.^32,33,34 People on low incomes eat lower amounts of fruit and vegetables despite spending proportionately more of their disposable incomes on food. Proportionately people on low incomes pay more for food; local shops charge more and have worse range of foods.^35,36,37 Judged against the lofty goals of world commitments such as the 1992 International Conference on Nutrition, England experiences insecurity at household level and in lower socio-economic groups.

Many people on low incomes inhabit areas which have been abandoned by retailing. As hypermarketisation has grown, geographical areas -- in towns and rural areas -- have emerged with little or no food retail provision. This is the problem of so-called food deserts.^38,39,40 Since the early 1990s, research has suggested that although there is diversity of experience -- not all areas are the same ^41,42 -- there is general agreement within the literature that the retail facilities 'frame' the options available to people on low income.

A recent study of Sandwell, an area which is ranked the seventh worst for ill-health in England and where a third of households had gross incomes below £5,500 a year and where a third do not have a car, has shown that while there may be shops apparently within 'range', there are large networks of streets and estates within Sandwell where no shops selling fresh fruit and/or vegetables exist.⁴³ Moreover, where such shops do exist, they are often expensive. Map 1 gives a map of Sandwell showing how large areas may be food deserts. However this is defined, measured against international commitments to provide the population with food security, current English (and UK) food and farming policy and practice are clearly failing a sizeable and vulnerable portion of England.

New mapping techniques such as that used in the Sandwell study should be taken up by DEFRA and used to frame as well as implement planning guidelines. In addition, local authorities and the various bodies replacing health authorities should set up standing committees to monitor food access and food inequalities within their localities. Their findings should be made public and should inform revisions of local strategic plans.

To get access to a healthy diet can necessitate the expense (financial and temporal) of travel by car or public transport. Thus the price of transport is an additional or externalised cost. There is also some evidence that healthier foods cost more. In a comparison of a 'regular' basket of foods with a 'healthier' basket -- the latter replacing skimmed milk for full-fat, wholemeal bread for white, low fat for full fat products, etc. -- the more healthy basket of goods costs considerably more than the less healthy (see Table 6 for a six year follow-up by the Food Commission).⁴⁵

Source: Davey/Food Commission 2001 ⁴⁶

Such findings suggest that the recommendations of the Acheson Inquiry into Inequalities in Health that there should be 'policies to increase the availability and accessibility of food stuffs to supply an adequate and affordable diet' (p65) and the 'further development of policies which will ensure adequate retail provision of food to those who are disadvantaged' (p66)⁴⁷ are not being implemented. There is an urgent need to do so if the Government is going to meet its health inequalities targets.

Faced by such mounting evidence across the UK, food retailers have been understandably defensive and argue that this lack of 'demand' for healthy food due to low incomes is not of its own making. While the matter of income and spending power is not within the remit of the sector, current industry strategy is not helping either. Indeed, their actions -- undercutting local grocery stores, encouraging an oil-dependent fuel economy, siting of stores -- all exacerbate the general picture of poor diet, poor 'walking' access to healthy food, poor exercise and therefore poor health outcomes. As the Social Exclusion Unit's PAT 13 report showed, what is needed is an urgent injection of new thinking into local retailing -- not just for food.

The DALYs data (tables 3 and 4 earlier) suggested that the food and nutritional contributions to inequalities in health and the rewards from addressing them may be substantial. Estimates from WHO for the 'costs' of poor nutrition, obesity and low physical activity for Europe, calculated in DALYs is 9.7%, which compares to 9% due to smoking.⁴⁸ Recent analysis suggested strategies to promote healthy eating and dietary change were among the most cost-effective of methods of preventing cardiovascular disease.⁴⁹

On average, people on the lowest incomes are the most likely to have inadequate nutrient intake and the least diverse pattern of food intake and nutrient base. They are particularly likely to have low intakes of fruit and fresh vegetables. The gap in fruit consumption in particular has widened over the last two decades. A recent, special National Food Survey analysis on income, expenditure and consumption concluded that disparities in expenditure have grown since 1985/87, with currently about £10 per person per week spent on food by households in the lowest income decile, as against £25/person/week spent by those in the highest decile.⁵⁰

The shortfall in the lowest income group is greatest for alcohol (71%) and fruit (53% below average), although those in the lowest income groups spend the greatest proportion of income on food and drink (28% vs 17%). However, because those in lower income households purchase cheaper commodities as well as different products to high earners, the differences in commodity consumption, and nutrient intakes, is not as large as the expenditure differences might suggest. Nonetheless, fruit consumption by the lowest income group was only a third of that of the top income group (about 560g/person/week compared to Kg1.7/person /week). Fruit and vegetable consumption, and production and distribution, therefore features as a major theme in our discussion.

The UK fresh fruit and vegetable market was valued at £7.41bn in 2000, having increased by 1.2% since 1999. The UK supplies a large percentage of its own fresh vegetable requirements but there has been reducing output, increased prices, and the number of vegetable growers is falling. The fruit market, in contrast, depends heavily on imports. The long-term trend shows a decline in per capita consumption of fresh vegetables but an increase in per capita consumption of fresh fruit. Nevertheless, UK consumers still consume less fresh fruit per head than many of their European counterparts. While processed foods are becoming more popular, fresh produce still accounts for 61.6% of the value of all fruit and vegetable sales.⁵¹

But, according to the Minister for Public Health, Yvette Cooper and Jacqui Smith (then Minister for Education), many children -- particularly those growing up in poverty -- are eating considerably less than the recommended five portions of fruit and vegetables a day, while consumption of fruit and vegetables by children seems to have fallen over the last twenty years.⁵²

In fact, fewer than 20% of 2-15 year olds eat fruit and vegetables more than once per day and the typical diet of children and adolescents is rich in fat, sugar and salt. A study of 2635 schoolchildren aged 11-16 years in 111 schools in England and Wales in 2001 found that on average they reported that they consumed only a third of the recommended 35 portions of fruit and vegetables a week. 5% of the sample reported that they had eaten no vegetables at all in the previous seven days, and 6% reported eating no fruit in that period, too.⁵³ There is a strong link between social class and poor diet: among boys and girls aged 2-15 years there is a decrease from social classes I/II to IV/V and from higher to lower income households in the proportion consuming fruit and vegetables with a related increase in the proportion consuming sweet foods, soft drinks crisps and chips. One significant factor -- among many -- that may encourage children to have a poor diet is 'Cause Related Marketing' by food and drink companies ⁵⁴ which also act to frustrate the intentions of Ministers as stated above.

There is strong evidence for a protective effect of fruit and vegetables against chronic diseases such as CHD and cancer.⁵⁵ The World Health Organisation (WHO)⁵⁶ recommended that people should eat at least 400g (approximately 5 portions) of fruit and vegetables a day, which could reduce overall deaths from chronic diseases (such as heart disease, stroke and cancer) by up to 20%.⁵⁷ While the scientific evidence of the benefits of consuming fruit and vegetables are convincing the challenge remains one of translating policy into action, particularly for those groups who have problems accessing fruit and vegetables or accepting the cultural challenge to current eating habits.

For the UK population as a whole, the deficit in fruit and vegetable consumption is considerable. According to the targets set for consumption of fruit and vegetables by the Committee on Medical Aspects of Food Policy (COMA) -- now replaced by the Standing Advisory Committee on Nutrition -- on current trends it will not be until the year 2047 that the overall population target is met (see Figure 4).⁵⁸

One attempt to address these challenges is set out in the English NHS Plan ⁵⁹ which endorses the need to eat more fruit and vegetables and set out plans for both a National School Fruit Scheme and a Five a Day programme to help increase fruit and vegetable consumption. The purpose of the National School Fruit Scheme is to provide free of charge a piece of fruit on each school day to over 2 million children between the ages of four and six from 2004. The Scheme is not just aimed at increasing access but also educating by good practice and fostering an eating pattern that it is hoped will be maintained beyond kindergarten years.

It has been estimated that diet might contribute to the development of one third of all cancers. The Committee on Medical Aspects of Food Policy's (COMA) Working Group on Diet and Cancer concluded that, overall, the evidence is moderately consistent that higher vegetable consumption would reduce the risk of colorectal cancer, and that higher fruit and vegetable consumption would reduce the risk of gastric cancer. There is weakly consistent evidence, based on less data, that higher fruit and vegetable consumption would reduce the risk of breast cancer. Additionally, there is moderately consistent evidence that higher consumption of fruits are associated with a lower risk of lung cancer (although the effect of smoking is the major environmental consideration) These cancers combined represent a significant proportion of cancer burden in men and women. Even a small reduction in relative risk would have important public health benefits in terms of the absolute numbers affected. The World Cancer Research Fund estimated that increasing fruit and vegetable consumption could prevent 20% or more of all cases of cancer.⁶⁰

The results of a 1997 systematic review were consistent with a strong protective effect of fruit and vegetables for stroke and a weaker protective effect on coronary heart disease.⁶¹ Studies published since this review have also been supportive of a protective effect. For example, a recent study among US health professionals ⁶² found that each 1 portion per day increase in fruit and vegetable intake was associated with a 4% lower risk of CHD and a 6% lower risk of stroke, after controlling for other risk factors.

A recent survey for the Food Standards Authority ⁶³ found a high level of recognition of the need for more consumption of fruit and vegetable but less recognition of what constitutes a portion or of the recommended amounts as the following demonstrates.

• One third stated the correct number of portions of fruit and vegetables recommended for daily consumption.
• Far more considered the recommendation was less than five-a-day.
• There was confusion over portion size, 71% correctly identified an apple as one portion but only 33% correctly identified 2 plums and even fewer (25%) that 2 tablespoons of vegetables equals one portion.

In the UK, average consumption is 3-4 portions per day, though there are marked differences by region and between social groups - unskilled groups tend to eat around 50% less than professional groups. The National Diet and Nutrition Survey,⁶⁴ published in July 2000, found:

• children eat only two portions of fruit and vegetable per day, compared with expert recommendations for five portions;
• one in five children eat no fruit in a week and three in five eat no leafy green vegetables;
• children in low income groups are 50 per cent less likely to eat fruit and vegetables.
• in Scotland 46% of boys do not eat fresh fruit daily.⁶⁵

A recent report from the Office for National Statistics (ONS)⁶⁶ paints a complicated picture which belies the simple belief that those on low incomes consume less fruit and vegetables. The ONS found that those households where the head of household earned in excess of £640/week ate twice as much fruit as those households where income was less than £160/week. This is not surprising and would seem to be in line with general opinion and beliefs but the figures for vegetable consumption show a more complicated picture emerging. Low earning households, pensioners and those with no earner ate more fresh potatoes and fresh green vegetables than high income households. Households with one or more earners ate the same amount of vegetables regardless whether the head of households earned in excess of £640 or less than £160/week. The low consumption of fruit among low-income groups may be a result of cultural and financial restraints. The storage of fruit and its short shelf life in the home are constraints for those on low incomes.

A study of low income consumers for the Department of Health by Robinson et al ⁶⁷ found that affordability and accessibility were key issues in making decisions about food choice. Work in Sandwell points out the importance of establishing access issues, to ensure that the local population have adequate access to healthy foods.⁶⁸ These latter two studies highlight the importance of attending to issues of the wider public health determinants which impact on food choice such as physical and social access in combination with the more individual behavioural or psychological interventions such as the 'Food Dudes' programme.⁶⁹ on the assumption that interventions targeted at individuals will be most effective when the environment enables people to use appropriate knowledge and skills.⁷⁰

The great irony is that if the consumption of fruit and vegetables was to increase, as the Department of Health wishes, then this would mean a worsening of the food trade gap, the negative balance between imports and exports. Britain as a whole is in serious deficit. According to Food From Britain, which is charged to promote UK food exports, fruit and vegetables account for a significant proportion of the total food trade gap. While the export of fruit and vegetables has barely climbed, imports have increased rapidly (Figure 5). In other words, the amount of UK food imports massively exceeds its exports (see Figures 5 and 6).⁷¹ The financial deficit from this fruit and vegetables trade gap accounts for just under 40% of the total food trade gap. In 2000, the trade gap for fruit and vegetables was £3,657 million out of a total food trade gap of £8,592 millions (42.6%). Some of this, of course, is for fruits and vegetables that cannot be grown in the UK, but much can -- apples, pears, plums, soft fruits.

Although nutritional scientists are clear about the need to restructure the national diet, these messages have not been translated into policy or agricultural practice. According to national agricultural statistics, over the period 1989/91 to 2000, the area down to fruit production in the UK has declined from 46,700 hectares to 34,200 hectares.⁷² Total production of fruit in this period has declined from 527,000 tonnes in 1989/91 to 305,000 tonnes in 2000. Meanwhile fat production has remained unacceptably high. Although, milk production has declined slightly from 14,573 million litres in 1989/91 to 14,054 million litres in 2000,⁷³ some hard dairy fat production, meanwhile, has actually increased. Cheese, for instance, has grown from 305,000 tonnes to 344,000 tonnes in the same decade, and cream production has gone up from 231,000 tonnes to 258,000 tonnes in that 198/91-2000 period.⁷⁴

The message of such evidence is that, firstly, there is a public policy failure and, secondly, that production is not taking health advice seriously.

According to the International Obesity Task Force (IOTF), extrapolating from existing data, by the year 2025 levels of obesity could be as high as 45-50% in the USA, between 30-40% in Australia, England and Mauritius and over 20% in Brazil. The population of the England suffers from one of the most serious weight problems in Europe. The figures on obesity in England are set to get much worse (see Figure 7).

The health cost of obesity and lack of exercise is well documented.^76,77 It also has to be acknowledged that what may become a national health crisis is also a major business opportunity. A Target Group Index (TGI) survey by BMRB International found that 28.5% of respondents were trying to slim. As a result of this the potential market for slimming foods is vast. In 1999, the market was valued at £5.38bn. Reduced-fat products formed the largest sector.⁷⁸ There is an explosion of interest from food and pharmaceutical companies to produce 'magic bullets' - products (foods or drugs) which can address it.⁷⁹

Even those who favour such a technological solution to obesity admit that the complexity and multigenic nature of obesity might mean the pursuit will be long and hard. A simpler public health policy might be to structure living so that people eat less and take more exercise. This is not what current social frameworks encourage. (Why go to an expensive gym when exercise could be built into daily life?) Walking or biking in everyday is made harder and more dangerous just when it needs to be made the easy choice.⁸⁰ Food retailers have been significant drivers of this 'modern' but obesity-inducing lifestyle. If the UK does not take this route, it is likely to follow the USA where operations such as 'stomach stapling' (to constrain satiety and appetite) are an unnecessary but profitable drain on medical time and insurance.

Most worrying for the future is the spread of obesity among children (see Table 7). Of 800 children questioned by the Doctor-Patient Partnership, 200 admitted that they did not eat a proper breakfast, but instead snacked on crisps and sweets on their way to school.⁸¹ Data from a recent representative sample of 2630 English children showed that the frequency of overweight children ranged from 22% at age 6 years to 31% at age 15 years.⁸²

Source: Bundred et al ⁸³

Antibiotics have been key to the post World War II medical revolution. There is now concern that their value has been undermined, in part by the food chain. A treadmill effect has emerged in which 'bugs' develop resistance to antibiotics, i.e. promulgate new strains, almost faster than pharmaceutical researchers can develop new drugs.⁸⁴ When antibiotics were found to increase the capacity of intensively reared animals to grow faster (increase energy conversion), they were used prophylactically. Thus intensive animal production -- heralded as introducing cheaper meat to mass markets -- has contributed to the undermining of their value in human emergencies. The food chain cannot take sole blame for this. Other factors contributing to the include excessive prescription by doctors; non completion of courses by patients; and, not least, the astonishing capacity of bacteria to adapt and produce new antibiotic-resistant strains.⁸⁵

Recent best estimates indicate that more antibiotics are used in agriculture each year than in treating humans.^86,87 Evidence now links widespread use of antibiotics in animal feed, common to confined animal feeding operations,^88,89 with rising numbers of humans infected with bacteria that respond poorly or not at all to treatment with these same antibiotics, or closely related drugs.^90,91

After the discovery of a multi-resistant phage-type of salmonella typhimurium in the UK in the 1960s, the British Government set up an inquiry which reported in 1969.⁹² Not all its recommendations were followed.⁹³ Subsequently, in 1998, the House of Lords Select on Science and Technology concluded that imprudent use of antibacterial drugs had led to the development of resistance, making many worthless.⁹⁴ It concluded that the only way to retain effectiveness is to restrict their use. Such a conclusion is bad news for the intensive meat rearing trade but the grounds for action are pressing.

There is agreement that there is a remarkable growth of prevalence of new strains of salmonella, campylobacter and escheria coli. In 20 years some salmonella have experienced multiple drug-resistance growing from 5% to 95% today. Methicillin-resistant Staphylococcus Aureus (MRSA) has grown from 2% to 40% in just one decade.⁹⁵ A 1997 WHO conference recommended the termination of use of antibiotics as growth promoters if they are also used for human health.⁹⁶ So far governments have tended to make up their own minds. Sweden, for instance, banned the use of growth promoters in 1986. The UK banned use of penicillin and tetracycline only for growth promotion in the 1970's. Denmark ban virginiamycin in January 1998; and Canada has called for voluntary reduction. This patchwork situation will probably change following the EU's ban on use of four antibiotics -- bacitracin zinc, spramycin, virginiamycin and tylosin phosphate -- which took effect on July 1 1999.

The pig or poultry producer who shaves costs by using antibiotics is not meeting the cost of later ill-health when an antibiotic has declining effectiveness. The seriousness of this issue for the future of public health cannot be too heavily emphasised.

It can be argued that the achievement of a healthy mix of nutrients is the responsibility of individuals or of parents, in the case of children. This is a superficially attractive but ultimately limited argument. Although individuals can and do select different foods, often this is circumscribed by factors which they are less able to control, such as culture, history, income, physiological predilections and levels of information and education.

The degree to which children 'choose' is debatable but adult consumers are clearly disempowered if not given full information. The perception that information had been withheld about what was 'in' food and the degree to which judgments of risk were being taken by unaccountable experts or companies was key to the loss of confidence in the food supply chain and food governance during the food scandals of the last two decades. It was one of the motives behind the creation of the Food Standards Agency. But has there been any similar effort to improve public food education?

Most observers agree that the level of food education in this country leaves much to be desired. Practical skills in food are not on the English curriculum, for instance (yet have been retained in Northern Ireland). Yet since the 1970's, the dominant policy approach to food and health assumes an informed, educated and skilled consumer.

The track record of health education in transforming the toll of ill-health outlined at the start of this briefing is poor. This is partly due to an imbalance of funding. The budget for food advertising in the UK (almost £600 million p.a.) grossly outweighs the promotion of improved diets; the Food Standards Agency spends only 5% of its budget on nutrition. In 2000-01, it spent precisely £9.7 million on nutrition and diet analysis to help health promotion.⁹⁷ And while the recent Lottery grant to fund fruit for schoolchildren is to be welcomed, it is ironical that this has been funded from such a source rather than from general taxation.

Food labelling cannot on its own substitute for the imbalance of information and messages given.⁹⁸ From a policy point of view, there are mixed messages about declaration of ingredients. Some are positively declared -- additives for example while for others, such as pesticides, the consumer has no declaration and must assume they are present, but at safe and monitored levels, unless the product is expressly 'organic' (Table 8).

In 1994, according to Consumers International, 15% of all food advertising in the UK went on chocolate confectionery, while only 0.5% was spent to promote fresh fruit, vegetables and nuts.⁹⁹ In 2000, according to the Advertising Association, £596 million was spent on advertising food in the UK, with another £284 million on drink.¹⁰⁰ This was part of the total of £17,000 million spent on advertising in Britain. This represents a proportional decline of total UK advertising spend. According to data from ACNielson, which tracks advertising expenditure by product, only a tiny of amount of the total that they calculate, went on foods such as vegetables, fruit and fish, which have been shown to highly beneficial to health. Vice versa, foods which are high in fats, such as margarine, crisps, cakes, biscuits, meat products, etc., receive a proportionately large expenditure.

Source: ACNielson, Advertising Statistics Yearbook 2001 ¹⁰¹

As these figures suggest, food advertising tends to be directed at selling foods with high levels of fat, sugar and salt. Nutritionally, such foods should be kept to a minimum as they are associated with a diet that contributes to coronary heart disease, tooth decay, hypertension, strokes, gallstones and obesity.

Alongside specific food advertising is the growing but unregulated area of sponsorship and other forms of sales promotion. The most heavily advertised food to children, unfortunately, are also the least healthy. Children aged between 5 and 15 have a considerable effect on parental purchasing decisions and overall consumer trends. While this age group has a high level of actual spending power in certain markets, their indirect power, via their influence over the choice and opinions of parents, is even more considerable. It is for this reason perhaps that opinion polls have indicated that 54% of the public would like advertising to children banned and why the advertising industry feels particularly threatened by activities by consumer and public health groups seeking to protect children from unwelcome advertising and by 'Cause Related Marketing' sponsorship schemes.¹⁰²

Sales of snack foods - crisps, savoury snacks, nuts and baked snacks - reached £2.2bn in 1999. The largest market sector is crisps with sales of £1bn in 1999. Three brand groups - Walkers, Golden Wonder, and KP Foods - dominate the UK snack foods market with Walkers claiming over 50% of the UK crisps sector. Crisps sales appear to have reached saturation point, requiring the producers to consider alternative ways of marketing their products, particularly to children. Part of the answer has been found in Cause Related Marketing which uses part of the huge marketing budget of the snack food manufacturers to provide benefits of seemingly high social valuation by parents and which are unconnected to the product itself - in order to achieve a 'rub off' onto the product. The Walkers Crisps/News International 'Free Books for Schools' is the prime example of this strategy, for which it won the Business in Community Award for 2000. In 1999 over 2.3 million books, worth £12 million, were distributed to schools, with over 98% of UK schools taking part. Each school on average has received over 70 free books. By June 2000, the second consecutive year of the partnership, another half a million books had already been 'given away'.

While Business in the Community has applauded this scheme in fact, as the Consumers' Association has shown, it offers poor value to consumers. 50 packets of crisps, costing around £15, can earn a book worth, on average, £4. However, only seven out of the 157 books on offer 'cost' fifty tokens. Around half require five times as many and are worth only marginally more, on average £5.30. The Consumers' Association also notes that this scheme is in default of the Incorporated Society of British Advertisers (ISBA) guidelines entitled 'Best Practice Principles for Commercial Activities in Schools' since the scheme is a clear encouragement to 'engage in unhealthy activity'.¹⁰³

It is sometimes argued that if only the English cooked more, they would eat a better diet and have lower diet-related disease patterns. Food education exists in both primary and secondary schooling but the stress is more on theoretical aspects than on practical skills. The Department of Health joined with the former MAFF and the voluntary sector to express concerns about this from 1991.¹⁰⁴ Today pressure to reintroduce a practical element continues.¹⁰⁵ Certainly, over the last two decades there has been a decline in cooking, coinciding with a rise in eating-out, fast-food and changed lifestyles. Cooking seems to be moving from a chore to a leisure pursuit for the more affluent. Research also suggests that the amount of time the British spend cooking is determined not just by the skills base and inclination but by structural factors such as longer working hours, increased in wage female work and longer shopping travel times.¹⁰⁶ Pre-prepared meals and better cleaning products mean the average person spends two hours and 41 minutes less time doing domestic chores per week.¹⁰⁷ This is, however, balanced by an increase in the time spent shopping and on associated travelling to food suppliers, which has risen by two hours and 48 minutes per week. This is largely because of the growth of out-of-town supermarkets.^108,109

The relationship between cooking skills and health inequalities is not straightforward. Contrary to mythology, people on low incomes cook more than the more affluent, but they cannot afford to experiment with unknown or expensive ingredients.¹¹⁰ Cooking may be a contributory factor to (ill)health in that cooking skills can give people control over, and confidence with, their food. If there is a case for cooking, the evidence suggests that this ought to be on a population rather than individual or social class-based 'at risk' basis.

The population approach also emerges as critical with regard to physical activity. According to the Government's National Travel Survey, the average distance walked per person per year has been declining steadily since 1986. The average number of pedestrian journeys has decreased by 13% over the last 10 years. Car usage has grown considerably. People are using cars more often and going further, a trend in which the demise of local shops is a factor. By 1994-96, 60% of all journeys and 82% of total distance travelled was by car or van. Since 1986, the number of walking trips made by children and young people has fallen by 17% for those aged between 5 and 10 years, by 29% for those aged 11 to 15 years, and by 14% for the 16 to 20 year olds.¹¹¹

The General Household Survey provides data on why and when people walk, i.e. build exercise into their daily lives. The most frequent purpose of walk-only trips (c. 25% of all journeys) is shopping, followed by social or entertainment purposes (c. 20%). Walking to work only accounts for 6% of all journeys on foot, a decline from 8% in 1986. On the positive side, walking was the purpose of a third of countryside leisure trips and more than half of people walked alone. Women and men made a similar number of leisure visits to the countryside for walking.

The Social Exclusion Unit has noted that the health implications of the decline of local shops. The long-term restructuring of the retail market in the UK is long term (see Figure 8), but has accelerated with the huge increase in out-of-town superstores (usually defined as sites with more than 30,000 square feet of sales area). In 1982 5% of retail sales were out-of-town; by 1994 that had risen to 17%. In 1971 there were 21 out-of-town superstores. By 1992 there were 719.¹¹² In 2000, there were 960. In the period 1986-97, the number of independent stores declined by almost 40%. This means that eight independent shops disappeared everyday. Shopping journeys by car and the average distance traveled to shops has increased. According to the National Travel Survey, since 1985/86 the average number of shopping trips per person has remained fairly constant, but the average trip length increased from 2.9 miles to 4.0 miles.¹¹³ Overall, shoppers made 5% more shopping trips and travelled 45% further in 1997/99 than in 1985/86. There has been a radical transformation in mode of transport to all forms of shopping (see Table 10).

Source: DETR (2001) ¹¹⁵

For people on low income, this has had a remarkable impact, as a consequence of supermarkets externalizing their transport costs. If consumers have to have cars to get food from shops, transport is an extra food bill. The growth of food deserts -- areas with little or no shops -- adds a social burden. This problem was recognized by the Government's Urban Task Force to whose arguments this health analysis adds urgency.¹¹⁶

In health terms, the most significant feature of this retail restructuring has been the decline of local green grocers' shops and a squeeze on fresh produce in (street and covered) markets. In 1969, 8% of vegetables were sold through supermarkets; today, it is 72%. Greengrocer shops are today fairly rare, yet for supermarkets fruit and vegetables are a key profit centre.¹¹⁷ In price terms and on a like-for-like basis across all food items, researchers are agreed that supermarkets are cheaper than small grocers,¹¹⁸ but other studies suggest that grocers are considerably cheaper for fruit and vegetables.¹¹⁹

Another reason this new policy direction makes sense is current policy's unnecessary reliance upon non-renewable resources. Modern farming and food systems are heavily reliant upon fossil fuel, notably oil. In the 20^th century, most visibly, tractors replaced horses as the prime motive force on farms. Throughout the food supply chain, energy use expanded. Fertilisers are particularly heavy users of energy.¹²⁰ There is some evidence that organic systems of farming are less energy wasteful than conventional systems. A study by ADAS which looked at particular crops, found considerably less energy was used by organic systems of production than by conventional systems (see Figure 9). But given that around 70% of organic produce sold in the UK is imported, this should not be taken as a 'green light' to organics. The energy gains of organics as a method of production compared to conventional systems can be more than offset by the output being transported long distances. From a sustainability framework, the optimum policy is to consume food that is produced as locally as possible.

Over recent decades, there has been an unsustainable growth in transportation of both food to shops and of consumers to shops. The longer the oil-based transportation, the greater the emission of carbon dioxide (CO2), a greenhouse gas. The Intergovernmental Panel on Climate Change is recommending a reduction of between 60-80% of greenhouse gases just in order to stabilise climate change, not even to reduce it yet between 1989 and 1999 there was a 90% increase in agricultural and food products traded by road in the UK.¹²² Worse still, total UK airfreight doubled over the same period, and is predicted to increase at 7.5% each year until 2010.¹²³ Table 11 gives the emissions from different modes of transport.

Source: Jones 2001 ¹²⁴

These problems are self-reinforcing and have been many decades in the making. Decisions made about planning, transport, shopping, income, etc., have cumulatively created barriers to health improvement. The clustering of food retail outlets at the edge of towns and cities requires car and bus rides rather than physical activity. The speeding up of mode of transport in turn reduces, not just physical activity, but opportunities for social interaction and sense of community. This affects those on low incomes and the elderly being particularly hard hit as local shops disappear or are more expensive. Thus the food system contributes to the loss of social capital.

At the same time, there is evidence from the last 20 years of an emerging epidemic of obesity, where the cause is an environment rich in high energy dense foods and with less opportunity for physical activity. It is naïve to believe that this trend will be reversed by increases in individual responsibility and self-management alone. What is required is not just the development of an agricultural policy which meets and increases the opportunity for meeting the recreational needs of the public, but a food supply chain which reinforces physical activity where appropriate, to obviate a situation where inactivity is a major cause of ill-health.

At the heart of the policy challenge is the need to recognise the limits of individualised approaches and the benefits of population approaches to health. This was most elegantly set out by the late Professor Geoffrey Rose, who showed that there are not just 'high risk people' but also 'high risk populations'.¹²⁵ What is 'normal' in one culture may be abnormal in another. The Japanese, for example, eat a diet far lower in fats than the English (even though their diet is 'westernising'). What might be normal might still carry a high level of risk. Rose's argument is that if a large enough number of people have a mildly increased risk of developing heart disease, this may represent an awful lot of deaths. By attacking the whole population risk, the total risk can be decreased, not only for those few people who stand individually to gain a lot, but for the population as a whole.

The evidence is that people with high cholesterol levels have an increased risk of dying of heart disease. Using data from the MRFIT (Multiple Risk Factor Intervention Trial) study in the US, Rose showed that the overall death rate from coronary heart disease (CHD) in men was about 7 in 1000 over a six year study period, while the death rate in the lowest cholesterol group was 3 in 1000. In other words, the population death rate from CHD could be halved if everybody's cholesterol was reduced to that of the lowest people - a massive health gain. This poses a paradox for health promoters. A man who has a cholesterol of 8 is at serious risk: he has a 1 in 50 chance of dying in the next six years, as opposed to a 1 in 333 chance if he is in the lowest risk group. However, a man with cholesterol of 5 has a 1 in 200 chance, not nearly so dramatic. A population approach suggests that the best way to prevent such ill-health is to encourage the whole population to change its behaviour -- e.g. to reduce its fat intake to a Japanese level or to take exercise by walking to the food shops -- rather than by targeting advice or change at the people with the highest risks.

Whereas the UK had a population food and health strategy and policy in World War II, since the 1960s and 1970s, just when evidence about the need to change as a population grew, its strategy and policy have been limited to an individualistic frame of reference. The Government should accept that the individual lifestyle approach has serious policy limitations. A health-oriented Farming and Food Policy should be based on a population-wide approach. This would require a commitment from Government to:

• facilitate physical activity in everyday life;
• improve the availability of UK grown fruit and vegetables (to reduce food miles and unnecessary energy use in food supply);
• integrate health into retail planning and local structural development plans.

Current drivers in the food system have a tendency to externalise costs or for costs not to be born at all.¹²⁶ Early studies into the costs of current patterns of ill-health suggest that externalised costs are substantial although they are often left out of an analysis of the economic efficiency of food supply chains. More work is urgently needed.

As to the economic costs of different food and diet-related diseases, preliminary estimates have generally been compiled by different methods and by different researchers making comparisons difficult. In relation to diet-related diseases the British Heart Foundation Health Promotion Research Group, for example, currently estimate that coronary heart disease (CHD) -- constituting about half of CVD -- costs the UK £10 billion pa. These costs are made up of £1.6 billion in direct costs (primarily to the tax payer through the costs of treatment by the NHS) and £8.4 billion in indirect costs (to industry and to society as a whole, though loss of productivity due to death and disability).¹²⁷

We have not calculated comparable data for stroke (constituting about a quarter of CVD) or cancer, or indeed other diet-related diseases such as diabetes or dental caries. But all of these diseases are likely to have costs of a comparable order to CHD. It is reasonable to assume that, as with DALYs, about one third of these costs (at least for CVD and cancer) can be attributed to poor diets.

There has been some work comparing the costs of different diseases to the NHS. The NHS Executive estimates that CVD is responsible for about 12% of health service expenditure and cancer for 4% making a total of 16%. Given that health service expenditure is now about £40 billion p.a., this makes £6.4 billion of which a third (£2 billion) can be attributed to poor diets.

Such estimates are probably conservative. The National Audit Office has recently stated that: "[o]ur conservative estimate is that treating obesity cost the NHS [in England] at least £½ billion in 1998. The wider costs to the economy in lower productivity and lost output could be a further £2 billion each year."¹²⁸ It should be noted that some, but not all, of these costs will be included within the costs of CVD and cancer discussed above.

In relation to the economic costs of food-born diseases, the Food Standards Agency estimates that the direct and indirect costs of food poisoning are £0.35 billion p.a.¹²⁹ and the direct and indirect costs of vCJD are £0.55 billion p.a.¹³⁰ Although these costs are substantial, they are smaller than the cost of diet-related CVD and cancer.

The financial cost of BSE to the public purse has been immense, over £4 billion for the UK alone, with a huge bill rising in the EU as slaughter policies are put in place.¹³¹ In 1998, the cumulative expenditure by UK Agricultural Departments in response to the BSE crisis, from 1996 to 2001, was forecast to be £4.2 billion.¹³² The bulk of that expenditure was, and will be, for compensating commercial enterprises, especially compensation to farmers for the removal of cattle over 30 months of age from the human food chain and support to the slaughtering and rendering industries. The figures also include expenditure on research programmes and administration.

The costs of BSE to the private sector have also been considerable. The ban on British beef exports in March 1996 led to the complete loss of a trade worth £700 million per year.¹³³ In the 12 months after March 1996, the total value of the market for UK produced beef fell by an estimated 36% in real terms (a combination of loss of exports and the drop in domestic demand), amounting to an estimated loss of value added to the UK economy of £1.15 billion.¹³⁴ It would be premature to try to provide precise estimates of the total costs of BSE, not least because we still cannot estimate how many people will eventually succumb to vCJD; there may be no more than another 50 cases, or there may eventually be up to a million cases.¹³⁵

Although the costs of these agricultural-induced crises (BSE, FMD, vCJD) are huge, they tend to be time-limited. The bill for the recent Foot and Mouth Disease outbreak was £2.7 billion by November 2001,¹³⁶ but the last extensive outbreak was in 1967.

The Common Agricultural Policy (CAP) is the biggest illustration out of date priorities continuing to frame the current policy agenda. CAP was born out of the ashes of World War II's food deficiencies. The architects of CAP and the Food and Agriculture Organisation's World Food Programme argued that what was needed was to unleash investment and science to raise productivity. If adequately distributed, they assumed that public health would improve. By the mid 1970s, this model was already adequate but CAP has persisted year by year. CAP now accounts for about half of total EU budgets with an expenditure in 1998 of •38,748m. It is the most politically divisive EU policy and symbolises all the difficulties of food policy reform. Europe still lacks a commitment to create a Food Policy rather than an Agriculture Policy. In 1999 the EU was paying an average subsidy of £11,790 per farmer, which cost the average British family £10 per week. The Common Agricultural Policy (CAP) stands accused of overseeing a system of European agriculture that causes enormous damage to the environment and rural livelihoods.¹³⁷

In on area of health costs one focus of action has been much delayed. Tobacco is the most heavily subsidised crop per hectare. In some areas, notably Italy, farmers are claiming high subsidies while continuing to grow varieties of tobacco for which there is no demand within the EU. Most of this tobacco, much of it very high tar, is exported to Eastern Europe and the developing world. The European Commission recognises that CAP subsidies need to be re-evaluated and the system will need to be reviewed in 2002.¹³⁸

The evidence is also mounting as to CAP's externalised costs. These are direct and indirect health costs such as contribution to cardiovascular disease and food poisoning treatment, summarized in the French Presidency document.¹³⁹ Environmental assessments for pesticide and nitrate pollution are also measurable for issues such as loss of amenity, cultural dislocation, decline of employment, losses of wildlife, hedgerows, stonewalls, soil erosion and carbon losses from soil.¹⁴⁰ Pretty and colleagues have summarised such for the UK (see Table 12). The key point is that the promotion of health should be part of, not separate from, such analyses.

Source: Pretty et al, forthcoming ¹⁴¹

Current policy objectives, in the UK and through the EU, were set half a century ago. The food sector has done what it was asked to do, namely increase production. What is now needed is the modernisation of farming and food policy to meet needs appropriate to the 21^st century. This will require:

• New national food and farming policy
• New drivers for the food sector involving government, the industry and civil society
• A commitment to a population-based perspective on food
• A commitment by Government to give greater priority to health in the CAP and European food policy reform process

UK food policy has a rich history. It has been fractured by an important dichotomy: Quantity versus Quality - and within this dichotomy two further oppositions, the consideration of home production versus external supplies, and food cheapness versus security. Addressing these will require a change perspective.

A central policy consideration over the years has been the long-term commitment to ensure food security. In the early to mid 19^th, a policy debate raged over support for agriculture. This culminated in the victory for trade interests, symbolised by the (1846) Repeal of Corn Laws, after which support and tariffs declined. Dislocation of supplies in World War I and ll led to a re-think. Although rationing reduced the gross inequalities that had so alarmed public health specialists in the 1930s, it did so in dire circumstances. A new post war regime, based on ensuring more stable supplies, was laid out in the 1947 Agriculture Act. This set out to rebuild UK agriculture through marketing boards and a subsidy system, based on deficiency payments. That regime in turn was altered by the UK's 1974 entry to the Common Market and the Common Agricultural Policy (CAP) system of price support mechanisms.

CAP has never been a static system, but broadly works by using production supports and export restitution (paying the difference between world market prices and EU prices). From a health perspective, the problem with this changing set of policies is that the notion of health utilised is crude; it assumes that adequacy of supply will deliver health. This, as England shows, is self-evidently not true.

Over the last two decades, food safety concerns have risen, when in the 1970s they were considered to have been banished to the history books. As with the quantity considerations above the policy roots are also long standing. Policy clashes peppered the mid 19^th century, culminating in the Food Act of 1875, which still provides the foundation for food safety thinking.¹⁴² The Food Safety Act 1990 reiterates the core 19^th century concept that "food shall be of the nature, substance and quality demanded." We believe this still to be a valuable objective towards which to orient a health-enhancing policy. 19^th century practices such as addition of lead, chalk etc have been controlled - with the exception of deliberate addition of water ('why sell food when you can sell weight?') in frozen foods. In their place are the products and by-products of food science and technology such as additives, pesticides, antibiotics, hormones and other residue sources, which are viewed by critics as unnecessary risks and by industry and proponents as by-products of progress, safe as long as they are properly controlled. Untangling the health dimension of this complex debate and web of evidence is beyond the scope of the present paper, but we are cautious about dismissing the case about such adulterations, contamination and residues as being scare-mongering.

The proposed health approach to Farming and Food Policy requires health improvement to be a priority throughout the entire food supply chain. Setting policies for farming alone would be inadequate. If farming, for instance, reduced its production of fat, but processors and manufacturers merely imported more, the health impact on the population as a whole would be unaffected. Equally, if consumers, as they have been doing, cut down on the direct use of salt (in home cooking, at the table) but processors add salt in increasing amounts, the impact on hypertension and strokes could be undiminished. A whole supply chain approach has to be intrinsic to any new Food and Farming Policy.

In order to make these changes it is important to understand some of the driving forces in the food supply chain, which are not simply due either to the market, the industry or government policy, but an interaction between these factors and others. The food economy over the last half century has experienced huge change in both diet and production. New products, processes (both on and off the land), distribution (supply chain management) and marketing (e.g. advertising) have had an astonishing impact on health, environment and culture. A spiral has occurred in which changing supply chain features have both fed and reacted to changing aspirations and food culture. Table 13 gives some key features, by sector.

Table 14 gives some dimensions on which current food supply can be audited. Broadly, the food supply chain is moving towards the left hand column, when there are good health reasons for why it should move to the right.

Source: Lang 1999 ¹⁴³

The UK has 'signed on' to two levels of commitment to give greater priority to health in food policy. One is through the EU, the other through the World Health Organisation European Region. Legally, the UK is bound by the EU's requirement under the Amsterdam Treaty to give health a high priority in EU policy. The UK is already associated with international commitments of varying legal weight which could help frame the Government's thinking. Some key food-relevant International agreements on the environment, safety and nutrition are given in Table 15.

While the UK's food and farming system has been weathering its period of crises and scandals, since the late 1980s, a European dimension to food and health policy has become increasingly evident. With the Single European Act 1986, the system of health protection and inspection was replaced by a new regulatory structure designed to facilitate intra-EU trade, and sweeping away the tortuous process of trying to set 'Euro-recipes' for foods, and in its place instituting a more liberal approach, bound by application of 'due diligence' to ensure that foods were fit and safe to consume.

Almost as soon as this régime was in place, the BSE crisis broke in the UK. Over the last decade and a half, bit by bit, the EU has had to institute a tougher structure, at one point essentially putting the entire UK meat industry into quarantine. The policy fall-out from this period of turbulence continues. Structures in Brussels have been reformed and new institutions are or have been set up: DG Sanco is a directorate general entirely for consumers and health; the Food and Veterinary Office monitors the national food hygiene auditors; the new European Food Authority comes into existence in 2002.

These political and institutional changes have been accompanied by much less remarked toughening of public health perspectives at the European level (see Table 14 for some milestones). Since the BSE, Foot and Mouth Disease (FMD) and other safety crises, there is a greater willingness for the EC to promote public health more actively. Three EU initiatives have coincided with long-term initiatives within the European Region of the World Health Organisation. These are:

• Food Safety White Paper Reform process. In January 2000, the EC published a Food Safety White Paper. This proposed a restructuring of EU food law and the setting up of the European Food Authority. 84 pieces of legislation were announced, only two of which were about nutrition. The emphasis is on safety.¹⁴⁴ The Council of Ministers has already approved the text of the new General Principles of Food Law and the setting up of the new European Food Authority and its remit.
• Eurodiet. This was a three year process for setting up a EU-wide system of dietary advice and nutrition information gathering. This process was completed at Crete in May 2000 and made proposals for data-gathering, health promotion and food and health policy.¹⁴⁵ These population goals are summarised in table 2.
• The French Presidency initiative. This culminated in the Brussels Council Resolution of December 8, 2000 with a list of Actions agreed by Health and Social Affairs Ministers.¹⁴⁶ This should lead to actions such as Health and Environmental Impact Assessments of the Common Agricultural Policy.
• WHO European Region Food & Nutrition Action Plan. WHO-E involvement in food and health policy is deep. In 1988, the WHO produced a major analysis of diet and disease and outlined dietary targets for member states.¹⁴⁷ In the 1990s, exhaustive consultations were held with member states. This process culminated at the WHO European Regional Committee on September 14, 2000 where the 51 Member States agreed a programme of action and preparation of scientific arguments and data running up to 2005.¹⁴⁸ This process worked closely and in harmony with the French Presidency initiative (above). A scientific policy paper is in preparation and due to go to consultation in 2002 leading to a Ministerial meeting in 2002. Member states are committed to promote a new three pillar policy framework, giving equal emphasis to nutrition, safety and sustainable food supply (see Figure 10).

The WHO-E approach in Figure 10 is the model that accepted by all 51 member states in September 2000. As member states of the WHO, all 15 EU Member States are signatories. Its acceptance ran parallel to the French Presidency process outlined above. This could be the model that should infuse England's new Farming and Food Policy as well as reforms of major policy areas outside, notably CAP. The approach is simple, a joint commitment to good nutrition, food safety and sustainable food supply.

Access to a healthy mix of foods and achieving the right balance of nutrients is essential for humans to achieve their physical and intellectual potential. Figure 11 represents the lifecycle, highlighting moments in which food is critical in generating either health or ill-health. It also highlights how the food supply chain requires and can distort natural, social as well as economic capital.

Figure 12 represents the institutional and policy points which frame the potential of people to achieve a good diet. This indicates how the food supply chain is integrated. Thus a change in one part of the system requires change in others. The goal of any new food and farming policy would be to set the overall framework to enable the entire food and farming system to move deliver health improvement, rather than health failings.

Although this Report has argued that there can and should be congruence between human and environmental health in policy, there are key policy areas where health goals currently conflicts with environmental goals. Fish is a prime example; if people were to consume more fish in line with nutritional advice, fish stocks would be even more rapidly depleted than at present. Across the world, 5% of humanity consumes 45% of all meat and fish, while the poorest 20% consume only 5%. In 1975-95, the global marine catch almost doubled, and now an estimated 60% of fisheries are at the stage at which yields decline.¹⁴⁹ The Food and Agriculture Organisation (FAO) sees the problem as the world "having too many vessels or excessive harvesting power in a growing number of fisheries," yet governments are subsidises the fish industry an annual $14-20bn, equivalent to 25% of sector's revenues.¹⁵⁰ This merely underlines the importance of ensuring that health and environmental goals are congruent. The collapse of the small fishing industry with the arrival of large industrial fishing fleets which deplete breeding stock and damage grounds suggests that how fish are harvested is as important a policy consideration as whether they are. The work of bodies such as the Marine Stewardship Council and setting limits on intensive fish farming is important if fish are to be available for future generations. That the UK, an island, now draws in huge amounts of fish derived from long-distances, having mismanaged its own waters and fleets is a matter of concern from a health, not just environmental or employment, perspective.

The implications of how the actions of one sector can have an impact on others has now been brought to public attention by the crisis for tourism from Foot and Mouth Disease. But there are others. For example, the Food Standards Agency is aware of the absurd situation where UK regulations are restricting sales and therefore consumption of UK shellfish. This was noted by the Food Standards Agency task force on regulations and small businesses.¹⁵¹ The case illustrates a wider point, that unless there is a 'joined' up food and health strategy, combined pollution from other sectors such as farm slurry run-off, pesticide residues can restrict another from being viable. By contrast, as the FSA Task Force heard, France's integrated local approach to shellfish water quality control shows what can and should be achieved. Its seaside tourist trade also benefits. Everyone can win: tourism, human health, water companies, fishing, local economies, government agencies (local and national). But only if ecological and human health are seen as linked and not 'somebody else's problem'.

One goal to make food supplies more sustainable is to reduce their energy input. Sweden has recently set a target of reducing its total supply chain energy use by a factor of four by 2021.¹⁵² Animals, for instance, are notoriously problematic converters of energy (See Table 16. In order for the food and farming sector to produce food in a way that does not irreversibly effect the environment, various changes need to be implemented. These include a reduction of inputs -- pesticides, fertilisers, energy from fossil fuels and water -- per kJ of food for human consumption. There are various ways of achieving this. The simplest way would be to increase the production of plant-based foods for human consumption and to reduce the high level of meat and dairy production. This would be beneficial for environmental sustainability and human health.

Source: Garces (2001)¹⁵³ from De Hann et al ¹⁵⁴ and Spedding ¹⁵⁵

In a study looking at the implications of reducing the energy demands of, and fertiliser inputs, to the food and farming sector in Sweden, the Swedish Environmental Protection Agency found that one way of achieving this would be a reduction in the dietary intake of animal products and an increased intake of plan-based products.¹⁵⁶ Table 17 shows what the Swedish Environment Protection Agency, based on advice from the Swedish Food Administration, proposes would be both a healthier and a more environmentally sustainable diet for Sweden. Intake of animal products would be halved but if this could be attained energy consumption would be reduced by 30%, artificial fertiliser uses by between 20 and 40% and the acreage need to produce food would decrease.

The other main area of congruence between health and environmental goals for the farming and food sector is in the need for greater variety in agriculture crops and livestock. There are a number of reasons for increasing both the bio-diversity of both agriculture systems and of our diet.

In order to meet all the main population nutrient goals a number of different foods need to be consumed since no one food provides the appropriate 'balance' of nutrients. There is good evidence that the greater the variety of foods consumed the more likely it is the population (and individuals within the population) will meet nutrient goals. Similarly for environmental reasons maintenance of species diversity within ecosystems makes those ecosystems more sustainable.

In many agricultural economies, there is recognition that there has been a progressive reduction in the number of species and of varieties within species of crops and livestock. To the consumer, particularly in affluent societies, there may appear to have been an increase in variety but this has been largely imported. A growth in variety of brands or of processed foods on supermarket shelves should not be confused with a growth in biodiversity in the field. In fact, the 20^th century witnessed a serious reduction in varieties and a ‚concentration™ in varieties planted.

How could research strategy help produce better public health through food? And how could research contribute to the formulation and implementation of the vision for health in farming and food that this Report has indicated?

Scientific and technological research on food and agriculture in the UK is being conducted in, and under, several jurisdictions. They include government departments, universities, agricultural and veterinary colleges, research council institutes and in the private sector. Under the current régime there are very few incentives for anyone to devote resources to producing safer foods or healthier diets.

Government departments such as DEFRA and the DTI see their role as both encouraging industrial and commercial competitiveness and supporting the implementation of current policies.¹⁵⁷ They therefore invest in two main kinds of research. One kind is intended to facilitate the enforcement of existing regulatory standards, while the other supports the development by the private sector of cost-reducing process innovations and (economic) value-added product innovations. Neither department sponsors research to produce safer foods or healthier diets, nor do they provide incentives for anyone else to do so.

The Food Standards Agency's research agenda is under review but most of the Agency's research expenditure resources supports its ability to discharge its statutory obligations, in other words, to facilitate the implementation of the present regulatory regime, but far too few resources are devoted to strengthening the science base of food safety and nutritional policy-making.¹⁵⁸ The Agency is giving limited consideration to healthier diets, nor are they providing incentives for anyone else to do so. This is now required.

The universities, the agricultural and veterinary colleges rely for their research support on government departments, the research councils, the private sector and to a lesser extent the European Commission. Universities and colleges are, in many cases, well placed to respond to new incentives to research into producing safer foods and healthier diets, but the current pattern of incentives are pushing academic researchers in contrary directions. The Research Councils, such as the BBSRC and the MRC, do recognise that basic and strategic research could contribute to providing a safer food supply and healthier diets but work of that kind is a low priority for them, and levels of funding are meagre.¹⁵⁹

The private sector concentrates its R&D efforts on reducing its own costs and on developing innovative products which provide added economic value, but which are not necessarily safer or healthier. The private sector has no incentive to invest in reducing those costs that it is currently able to externalise, such as those consequent on the over-consumption of fats and calories and the under-consumption of vitamins, minerals and dietary fibre. The private sector has an incentive to invest in research that reduces the cost at which it can comply with the existing regulatory regime, but it has no incentive to produce safer foods or healthier diets, nor to invest in research that might indicate how unsafe and unhealthy foods and diets might be.

If we are to change our farming and food systems in ways that will contribute to improving public health we will need do more than just apply existing knowledge. It will be necessary to draw upon the knowledge and creativity of scientists and technologists. If their effort and imagination are to be harnessed to that project government departments, especially DEFRA and the FSA, will need to play a key role in creating a fresh incentive structure. Those incentives will need to be created by changing not just research policies but also by changing conventional approached to regulation. The current combination of minimum requirements and maximum permitted thresholds only provides incentives to comply with current standards, not to improve upon them. So-called 'compliance plus' corporate strategies are conspicuous by their absence from the UK food and agricultural sectors. In collaboration with the research councils, government departments will need to articulate, implement and invest in a new type of R&D strategy that will provide incentives for progress towards safer foods and healthier diets.

Research is also required into actions in local settings often prompted by national initiatives, such as the National School Fruit Scheme and a Five a Day programme. There is a clear need to develop Local Strategic Partnerships, integrating local food planning within Health Improvement and Community Planning. There will be a continuing role for the Health Development Agency in evaluating the evidence and helping turn evidence into practice.

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115 | DETR (2001). Travel to the shops. Personal Travel Fact Sheet 6, London: Dept Environment, Transport & the Regions, March. http://www.transtat.dtlr.gov.uk/facts/index.htm

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131 | Lobstein T, Millstone E, Lang T, van Zwanenberg P (2001). The Lessons of Phillips Questions the UK Government should be asking in response to Lord Phillips' Inquiry into BSE. A Discussion Paper. London: Food Commission/Centre for Food Policy TVU/Science Policy Research Unit University of Sussex

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138 | House of Lords (2000) Hansard WA Col 79 28 June

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140 | Pretty J, Brett C, Gee D, Hine R, Mason C F, Morison J I L, Raven H, Rayment M and van der Bijl G. 2000. An assessment of the total external costs of UK agriculture. Agricultural Systems 65 (2), 113-136

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150 | World Trade Organisation (1999). Trade and Environment Bulletin. 30 July

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157 | See eg http://www.defra.gov.uk/research/researchfrm.htm and http://www.dti.gov.uk/scienceind/index.htm

158 | http://www.foodstandards.gov.uk/research.htm

159 | http://www.bbsrc.ac.uk/science/areas/Welcome.hml http://www.mrc.ac.uk/miss_and_pol/mis_pol.html http://www.nerc.ac.uk/